One Third of All TKAs Labeled 'Inappropriate'

More than one-third of total knee arthroplasties (TKAs) in the US could be "inappropriate," according to a new study whose lead author is a Catherine Worthingham Fellow. Researchers involved in the study believe that reducing that rate will require "a consensus-based appropriateness classification system for US patients" for a procedure that is currently "highly reliant on subjective criteria."

The analysis, e-published ahead of print in the June 30 Arthritis & Rheumatology (abstract only available for free), looked at data from 205 individuals who received TKA for a 5-year span leading up to the surgery. Using a modified assessment system developed in Spain, researchers evaluated radiographic evidence, knee motion and laxity, and scores on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) to arrive at classifications of "appropriate," "inconclusive," or "inappropriate" for the patients. Lead author for the study was Daniel L. Riddle, PT, PhD, FAPTA.

The subjects studied were drawn from participants enrolled in the Osteoarthritis Initiative (OAI), a 5-year study of individuals at high risk of developing knee osteoarthritis (OA). For the TKA study, authors excluded participants who had rheumatoid arthritis, bilateral knee arthroplasty (or plans to obtain one in the next 3 years), or bilateral end-stage radiographic knee OA; used ambulatory aids other than a straight cane; or were men who weighed over 286 pounds or women over 251 pounds. The 205 individuals included in the final study were on average 67 years old at the time of TKA, with females making up 60% of the group.

Authors classified 44% of surgeries as appropriate, given imaging evidence, WOMAC scores, and motion analysis, with 34.3% of surgeries found to be inappropriate, and 21.7% designated as "inconclusive." Going into the study, researchers expected the "inappropriate" rate to be closer to 20%.

According to the study, subjects classified as inappropriate generally had either mild or moderate symptoms as measured via WOMAC or low scores on the Kellgren and Lawrence (KL) scale classifying arthritis pattern and severity. "Given that most of these subjects either had pain and functional loss profiles that were less than half that of typical patients undergoing TKA or they had no joint space narrowing, it seems reasonable to question whether TKA was the most appropriate intervention for this subgroup," authors write.

The study acknowledges that this kind of analysis should not be applied to individual patients, but could be appropriate across patient groups. Use of analyses like the one studied could help to lessen the "extensive variation among TKA patients' characteristics," they write, adding that "it is likely this variation will continue until consensus is reached on the key criteria that drive decisions to recommend TKA to patients."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

Postacute Care Legislation Would Lead to Improvements in Standardization

Recently introduced legislation to standardize data used across postacute care settings is expected to move quickly through Congress, with a final vote likely to be held this summer. APTA has been working to influence this legislation and will continue to monitor its progress.

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (H.R. 4994/S. 2553) was introduced in both the House and Senate on June 26 by Senate Finance Chairman Ron Wyden (D-OR) and Ranking Member Orin Hatch (R-UT), and Ways and Means Chairman Dave Camp (R-MI) and Ranking Member Sander Levin (D-MI). If it becomes law, IMPACT would instruct the US Department of Health and Human Services (HHS) to standardize patient assessment data, quality, and resource use measures for PAC providers including home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs).

Supporters of the legislation, which include APTA, believe standardization would allow HHS to compare quality across PAC settings, improve hospital and PAC discharge planning, and use this standardized data to reform PAC payments in the future. APTA and other stakeholders have been providing feedback on the legislation since August 2013.

If passed, the legislation would:

Require PAC providers to begin reporting standardized patient assessment data at times of admission and discharge by October 1, 2018, for SNFs, IRFs, and LTCHs and by January 1, 2019, for HHAs.

Require new quality measures on domains beginning October 1, 2016, through January 1, 2019, including functional status, skin integrity, medication reconciliation, incidence of major falls, and patient preference regarding treatment and discharge.

Require resource use measures by October 1, 2016, including Medicare spending per beneficiary, discharge to community, and hospitalization rates of potentially preventable readmissions.

Require the Secretary of HHS to provide confidential feedback reports to providers. The Secretary will make PAC performance available to the public in future years.

Require MedPAC and HHS to study alternative PAC payment models due to Congress in 2016 and 2021-2022, respectively.

Require the Secretary to develop processes using data to assist providers and beneficiaries with discharge planning from inpatient or PAC settings.

The congressional committees have provided a summary (.pdf), including timelines. APTA will continue to work with legislators and the committees to move this legislation forward.

A new report comparing some common tests, procedures, and treatments has found that hospital outpatient departments (HOPDs) consistently charge more than community-based settings for the same services. For physical therapy, HOPDs charged on average 50% more than freestanding clinics.

In looking at physical therapy, the study's authors limited investigations to therapeutic exercise and manual therapy—"2 common physical therapy services" that accounted for $25.9 million of the $38 million spent on physical therapy among the claims analyzed, according to the report. Their findings: in looking at 136,000 services provided, "average prices were 41 percent and 64 percent higher in HOPDs for therapeutic exercises and manual therapy, respectively, than in community settings."

While not significant enough to account for the differences, the study notes that patients receiving physical therapy in HOPDs were somewhat "sicker" than patients receiving the other procedures, treatments, and tests studied.. " The authors write, "the health status difference might be explained because patients with hospital inpatient stays—say for a knee replacement—are more likely to be referred to physical therapy in HOPDs than in community settings."

Other findings in the report pointed to some even more dramatic differences. These include:

MRI of a knee was about $900 in hospital outpatient departments and about $600 in physician offices or freestanding imaging centers.

Charges for a basic colonoscopy averaged $1,383 compared with $625 in community settings.

The cost of a common blood test (comprehensive metabolic panel) was about 3 times higher in HOPDs—about $37 compared with $13 in community settings.

Authors write that the findings show that there is an opportunity for private insurers to reduce spending by looking at ways to incentivize the use of lower-priced community providers through excluding higher-priced providers from networks, implementing a tiered system that requires patients to pay more when using these providers, or capping the amount of payment to in network providers for particular services.

Postacute Care Legislation Introduced

Congress will be turning its attention to postacute care in Medicare with the introduction of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act in both the US House of Representatives and Senate this week. The introduction of the bill was announced in press releases from the Senate Finance and House Ways and Means committees.

The bicameral, bipartisan bill seeks to standardize data from assessment tools across all postacute care settings in order to inform future payment reforms. APTA has been providing input on this bill to the relevant congressional committees since August 2013 and will keep members updated on the progress of the legislation.

Foundation Receives Major Donation from Paris, Laureate Education

When he's not attempting to sail around the world, Stanley Paris, PT, PhD, FAPTA, FAAOMPT, is busy making a world of difference—this time, by donating $500,000 to the Foundation for Physical Therapy (Foundation). The donation, made with his wife Catherine Patla, was matched by Laureate Education Inc to bring the total Foundation contribution to $1 million.

The gifts, announced during the Foundation’s 35th Anniversary Gala in Charlotte, North Carolina, were made to help kickstart the next wave of research to transform the physical therapy profession, and are targeted to support research on the long-term outcomes of physical therapy.

"As a profession, our skills in restoring, maintaining and enhancing the physical functioning of the individual are not adequately recognized and integrated into treatment options," stated Paris in a Foundation news release (.pdf). "I believe our gifts will contribute to research and analysis of data in health care outcomes that demonstrate the efficacy and cost-effectiveness of physical therapy as a treatment option, compared with medical and surgical care, in such areas as hip, knee, and spinal complaints."

During his career, Paris has been involved in research, clinical practice, and teaching. He has published more than 40 articles in physical therapy, medical, and osteopathic journals, as well as a book, The Spinal Lesion. He is the recipient of several honors and awards, including the World Confederation for Physical Therapy’s (WCPT) 2011 Mildred Elson Award, WCPT’s top honor in physical therapy.

Paris is also an avid sailor, and late last year put his skill in service of the Foundation by attempting to sail around the world solo to raise awareness and funds for physical therapy research. Ultimately, equipment failures forced Paris to cut the trip short, but his adventures helped to highlight the aims of the Foundation. Paris recently announced that he will be making a second attempt in November.

Laureate Education Inc is a global higher education provider for health sciences and is a new owner of the University of St Augustine for Health Sciences, which was founded by Paris.

"We are extremely pleased to accept these 2 generous gifts," said Foundation Board of Trustees President William G. Boissonnault, PT, DPT, DHSc, FAPTA, FAAOMPT. "Once again, Stanley has shown himself to be a true friend of the Foundation. He continues to go above and beyond in helping to support our mission. These funds will be critical in our efforts to advance evidenced-based literature, the key to helping physical therapists improve the quality of life for so many Americans."

Medicare's Newest Fraud Prevention Tool is Paying Off

The use of predictive analytics—the same kind of technology credit card companies use to spot questionable spending activities—has enabled the US Centers for Medicare and Medicaid Services (CMS) to recover or prevent more than $210 million in improper payments in 2013. The savings are nearly double the amount identified during the previous year using the system, according to a report issued in June (.pdf).

According to CMS, the "predictive algorithms and other sophisticated analytics" that are now run nationwide against all Medicare fee-for-service claims are doing a good job of identifying fraudulent billing before payment is made. The process, called the Fraud Prevention System (FPS), is helping to move the agency away from heavy reliance on the "pay and chase" model that has met with mixed success.

The technology is analogous to the processes used by credit card companies to identify potential fraud. CMS monitors which Medicare identification numbers are used and by who (similar to tracking credit card charges made in one location when the cardholder lives far away from the place of purchase), billing frequency that is outside the norms (similar to flagging excessive credit card charges made in a short amount of time), patterns of billing (similar to credit card charges that echo patterns of known bad actors), and links between a provider and other known bad actors (similar to monitoring certain addresses for credit card charges).

CMS adopted the technology in 2011 as required by the Small Business Jobs Act of 2010. In its first full year of operation, the system produced a 3:1 return on investment. Last year, that ratio jumped to 5:1.

"The majority of health care providers enrolled in Medicare are honest, reliable business partners," CMS states in the report. "The FPS, as currently implemented, is not designed to flag transactions from this sort of provider; rather, the FPS is geared towards discovering egregiously improper patterns of billing–often amounting to fraud."

APTA is helping physical therapists (PTs) understand regulations and payment systems through its Integrity in Practice campaign that puts them in touch with tools and resources to promote evidence-based practice, ethics, and professionalism.

Docs Need to Get Up To Speed on Physical Activity, Nutrition

America's physicians aren't educating their patients on weight, diet, and physical activity because America's physicians aren't themselves educated on weight, diet, and physical activity. That needs to change, and soon, according to a coalition of organizations calling for more coverage of these issues in medical schools.

In a recently released white paper (.pdf), titled "Training Doctors for Preventive Care," the Bipartisan Policy Center, the Alliance for a Healthier Generation, and the American College of Sports Medicine write that "America's medical education and health care delivery system does not currently provide doctors with the experience or incentives to deliver messages about weight, diet, physical activity, and chronic disease in a consistent and effective manner." The paper asserts that even while obesity rates in the US have been climbing, the average number of hours devoted to nutrition education has been dropping to the extent that now fewer than 30% of medical schools provide the minimum hours of nutrition education recommended by the National Academy of Sciences. The group also released an infographic (.pdf) highlighting the problem.

According to the coalition, physicians are aware of the gap in training: a recent survey found that only 1 in 4 doctors feel they received adequate training on how to counsel patients on diet or physical activity.

In the white paper, the organizations make 9 recommendations that they believe will begin to fix the problem, including the development of standard nutrition and physical activity curricula, increased nutrition and physical activity requirements for residencies and continuing education, reimbursement of health services "that target lifestyle factors such as nutrition and exercise," and the expansion of board-accredited training programs "to create a cadre of experts in nutrition and physical activity who can teach health professionals." The coalition's recommendations were featured recently in a Washington Post report.

"Ensuring that medical professionals have the tools and expertise to address nutrition and physical activity is only one part" of a broader agenda to reduce obesity and chronic disease nationwide, the report states. "Nonetheless, it is an area where practical improvements are within reach, if policymakers and stakeholders work together to implement changes."

TBI Reauthorization Bill Approved by House

Prospects are good that government-sponsored research and data collection on traumatic brain injury (TBI) will continue now that the US House of Representatives has passed the TBI Reauthorization Act (H.R. 1098). APTA was among the organizations advocating for the bill, and some members were on Capitol Hill when the bill passed as part of an association "fly-in" on rehabilitation research.

The measure was passed by voice vote in the House on June 25, and will now move on to the Senate. If it passes the Senate and is signed into law, the act will provide funding to the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA) for TBI research and programs supporting individuals with brain injury. APTA applauds the passage of this bill in the House.

APTA provides extensive resources to its members on the role of physical therapy in brain injury treatment and recovery, and offers a TBI webpage that includes continuing education courses and links to other interest groups.

Rehabilitation Research Back in Advocacy Spotlight

They're baaack.

Physical therapy researchers returned to Capitol Hill June 24-25 to advocate on behalf of rehabilitation research funding, and to press for passage of a Senate bill that would better coordinate these efforts within the National Institutes of Health (NIH).

Coordinated by APTA and sponsored by the Section on Research, the "fly-in" involved 10 researchers from 10 states who met with staff of the House and Senate appropriations committees and their individual members of Congress to talk about the value of rehabilitation research. The researchers also urged passage of the Rehabilitation Improvement Act (S 1027), a Senate bill introduced by Sens Mark Kirk (R-IL) and Tim Johnson (D-SD), that calls for a working group comprising various NIH institutes and centers to update and streamline NIH's rehabilitation research priorities.

Physical therapy researchers made their case to members of Congressand their staff at the June 24-25 rehabilitation research fly-in.

The researchers were well-received, and were fortunate enough to be on Capitol Hill on the same day the House of Representatives passed the Traumatic Brain Injury (TBI) Reauthorization Act that ensures the continuation of research sponsored by NIH and the Centers for Disease Control and Prevention (CDC) (see related News story).

The fly-in was capped off by a Congressional briefing that featured Pamela Duncan, PT, PhD, FAPTA, and focused on the economic impact and return-on-investment of rehabilitation research. The American Occupational Therapy Association (AOTA) participated in the session, which was introduced by Rep Lee Terry (R-NE).

APTA cohosted the Return on Investment of Rehabilitation Science briefing.

EHR and Patient Safety: A Real Danger, Even for Experienced Users

When it comes to electronic health records (EHRs) and patient safety, experience might be a great teacher, but it doesn't guarantee straight-A performance. According to a new study, even in longstanding EHR systems such as the one used by the Department of Veterans Affairs (VA) health care system, "many significant EHR-related safety concerns … remain."

In a study of investigations of EHR-related safety violations launched through the VA's Informatics Patient Safety office (IPS) from 2009 to 2013, researchers looked at 100 closed cases at 55 VA facilities. Of those cases, 74 involved unsafe technology, and 25 involved unsafe use of technology, which authors write "most commonly involved the dimensions of people, clinical content, workflow and communication, and human interface." A majority of cases (70%) involved both unsafe technology and unsafe use. The study was published online in the June 20 issue of JAMIA.

According to the study's authors, the problems documented in the research underscore the importance of constant vigilance for issues that could impact patient care—both at the purely technological level and within the "sociotechnical" realm, where users must interact with the technology.

Researchers were able to use the data to tease out 4 types of safety concerns represented by the cases:

Concerns related to unmet data display needs. These concerns are related to what an EHR can and can't display, and occur when there's a "poor fit between information needs and the task at hand." Authors cited an example of a patient with a drug allergy who was given the drug due to a combination of human error and information gaps that made it seem as if an EHR warning was a "false positive."

Concerns related to software modifications. These issues center on the intended and unintended consequences of software upgrades or improper software configuration. By way of example, authors pointed to an upgrade to a disease management package that "erroneously escalated user privileges to place and sign orders."

Concerns related to system-to-system interfaces. Concerns in this area have to do with the ways systems talk to each other, and the possibility of one patient's records being mixed up with another's.

Concerns of hidden dependencies. Researchers identified several instances in which seemingly unrelated components of an EHR affect each other, such as the reassignment of a patient from outpatient to inpatient status resulting in the removal of certain medications from the patient's active medication list.

Authors chose the VA system in part because of its standardized and well-documented approach to investigations of EHR safety problems, and in part because it was an early adopter of EHRs. The VA's level of experience, however, didn't eliminate the problems. "Having a mature EHR system clearly does not eliminate EHR-related safety concerns," authors write.

Tackling these problems will take not only vigilance but an understanding that EHRs involve both technological and human elements. "Our study suggests that technology-based solutions alone will only partially mitigate concerns and that interventions to improve EHR-related safety should encompass the people, organizations, systems, and policies that influence how EHRs are used," the report states.

Award-Winning Privacy Notices Available

Physical therapists (PTs) have an opportunity to get the latest on notices of privacy practices, and find out how to install and customize award-winning open-source models for their own use.

The US National Coordinator for Health IT (ONC) will hold a free webinar on Thursday, June 26, at 1:00 pm ET to help health care providers and health plans access the notice models, winners of the "Digital Privacy Notice Challenge." The challenge, developed in collaboration with the Office for Civil Rights, asked designers to take the content of the model notices of privacy practices and create open source, user-friendly, and attractive designs. Those winning designs can be found on the ONC website and are now available for use.

Specialist Certification Exam Applications Due July 1 and 31

Application deadlines for the 2015 Board-Certified Clinical Specialist examinations are coming up in early or late July, depending on the specialty.

The application deadline for specialist certification in Cardiovascular and Pulmonary, Clinical Electrophysiology, and Women's Health is July 1, 2014. The application deadline for Geriatrics, Neurology, Orthopaedics, Pediatrics, and Sports is July 31, 2014. Online applications and Candidate Guides are available.

Individuals who successfully achieve board certification in 2015 will be recognized during the opening ceremony at the 2016 APTA Combined Sections Meeting (CSM) in Anaheim, California. For additional information, contact the Specialist Certification Program.

Too Many Questions Could Decrease Value of Patient Surveys of Physical Therapy

When it comes to getting an accurate take on patient experience with physical therapy, it may be a matter of the less asked, the better.

That's one of the conclusions reached in a Norwegian study that analyzed physical therapist (PT) patient surveys to find out whether a lengthy multidimension instrument could be simplified. Researchers used factor analysis to study results from a 41-item survey administered to 2,221 patients from 52 physical therapy practices, and found that more than a third of the questions did not yield meaningful results. Additionally, they discovered that the survey's 10 topical areas ("dimensions") could be reduced to 3: personal interaction, practice organization, and outcome. Results were published in the June 18 issue of BioMed Central (.pdf), an open-access journal.

"Quality of care from the patient's perspective is increasingly in the spotlight, but what exactly does it mean?" authors write. Often, they argue, it's hard to extract meaningful data from lengthy patient surveys that attempt to cover too much ground—respondents are quickly fatigued and tend to be less discerning in their answers, resulting in high overall scores and little variance. With these kinds of scores, authors write, "it becomes very difficult to distinguish high performing practices from practices with lower quality of care."

Researchers started by administering a 10-dimension, 41-item questionnaire that included areas such as accessibility, accommodation, communication, "physical therapist's approach," and "patient-centeredness," among others. Through an analysis of the performance of individual items in each dimension, researchers were able to identify the items that were consistently high-rated, with minimal (or no) variation. Once these were set aside, authors examined the remaining questions and determined that they could be regrouped into a much more straightforward, 3-dimension set of 28 questions that got to the heart of patient experience.

Authors suggest that the streamlined questionnaire could be administered "every 3 years or so" to a random sample of a practice's patients. They also recommend that practices include "a visible and mandatory complaint desk (physical or digital) … to monitor the quality of care at all times."

"Sharpening the definitions of the patient's perspective will help better measure the quality of care," authors write. "Patients do not benefit from too many vaguely formulated dimensions, but with 3 clear dimensions they can compare practices with ease on the dimensions they value the most."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

Consumer Group Voices Opposition to Unnecessary Tests

Is that advertised offer of a low-cost screening for stroke risk and heart disease good public health outreach or an "unethical" exercise in "fear mongering?" According to a consumer group that issued strongly worded letters to 20 hospital systems, the answer is clear—and hospitals need to do something.

Public Citizen announced last week that it is calling on hospital systems across the country to sever partnerships with companies providing the screenings, which are usually well-advertised and often provided in buses adapted for the purpose. Public Citizen asserts that administering the screening to asymptomatic, unselected individuals is an "unethical" and "exploitative" practice that "is more likely to cause harm than benefit."

The group's efforts are focused on screening packages from HealthFair that include 6 tests: echocardiogram, electrocardiogram, carotid artery ultrasound, abdominal aortic aneurysm ultrasound, hardening of the arteries test, and peripheral arterial disease test. When administered to asymptomatic individuals, the group writes, the tests can yield false-positive results that can lead to "unnecessary, risky, and costly diagnostic procedures and treatment interventions" or can result in overdiagnosis, "in which individuals are diagnosed with conditions that will never cause symptoms or death."

In its letter to hospitals, Public Citizen minces no words about the screenings. "It is exploitative to promote and provide medically nonbeneficial testing through the use of misleading and fearmongering advertisements and solicitations in order to general medically unnecessary but profitable referrals to your institution," the group writes, adding that "this screening violates the ethical principles of beneficence … and nonmaleficence."

The questions around the appropriateness of certain tests are similar to other efforts being made within the broader health care provider community. For instance, the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign is centered around lists of procedures (.pdf) that tend to be done frequently, yet whose usefulness is called into question by evidence. APTA was 1 of the first 3 nonphysician organizations invited to join the campaign, and the association has included its participation within APTA's wider "Integrity in Practice" initiative.

2014 APTA Component Award Winners Recognized

Real-world innovation and excellence in support of the physical therapy profession were on display when APTA announced this year's component awards. Recognitions took place at the Component Leadership Meeting on June 8 in Charlotte, North Carolina.

This year’s Innovative Component Award was given to the Tennessee Chapter for its creative partnership with the Tennessee Titans professional football team. The chapter hosted its annual conference in the Titans stadium and sponsored radio ads across the state focusing on the benefits of working with a physical therapist (PT). The Kentucky Chapter was also recognized with an Innovative Effort Award for its work to establish collaborative relationships with the state's occupational therapy, speech-language-hearing pathology, and athletic trainer associations.

In the Outstanding Component category, the Indiana Chapter and the Washington Chapter were acknowledged for their exemplary legislative efforts for direct access and spinal manipulation, respectively. The Oklahoma Chapter was recognized as the outstanding small chapter, while Illinois and Florida chapters received the award for outstanding large chapters.

Other award winners were the Alabama Chapter, which partnered with APTA’s Learning Center to create an online jurisprudence course to help licensees fulfill state requirements for license renewal; the Aquatic Physical Therapy Section which partnered with the APTA Learning Center to create the new Certificate of Aquatic Physical Therapy Clinical Competency program; and the Section on Pediatrics, which was acknowledged for expanding the international reach of its Pediatric Physical Therapy journal.

WCPT Accepting Award Nominations

Feel like yelling from the rooftops to tell the world about an outstanding physical therapist (PT)? Come down. There's a safer way.

The World Confederation for Physical Therapy (WCPT) is seeking nominations for its awards program that honors PTs who have contributed to the profession or global health at an international level. The WCPT deadline for nominations is August 31; nominations seeking support from APTA must be submitted to APTA staff by August 15. APTA is a member of WCPT.

There are 4 award categories open to nomination by WCPT’s member organizations, regions, or subgroups: the Mildred Elson Award, the International Service Award, the Humanitarian Service Award, and the Leadership in Rehabilitation Award. Descriptions of the awards, eligibility criteria (.pdf), and lists of past recipients can be found on WCPT's awards webpage. Nomination forms are required for all submissions and can be obtained by contacting René Malone.

Awards will be presented during the 2015 General Meeting and Congress May 1-4 in Singapore. Contact René Malone with questions.

Oncologists Say AMEN to Conversations With Patients Hoping for a Miracle

Physical therapists (PTs) who find themselves the bearer of disappointing news for their patients and clients may want to take a cue from the Johns Hopkins Kimmel Cancer Center, whose oncologists are using a new tool that helps them navigate conversations with patients counting on a miracle to turn a bad prognosis around.

Called the AMEN (Affirm, Meet, Educate, No matter what) protocol, the tool provides a roadmap that allows the health care provider to acknowledge and respect patients’ belief systems while continuing to educate them on their diagnosis and continuing treatment. AMEN consists of a recommended script for talking with patients, to "maintain trust and foster open and honest communication as the care plan is being discussed," according to a news release from the Kimmel Center.

The protocol walks providers through a 4-part conversation in which they affirm the patient's beliefs, meet the patient and family where they are in terms of hoping for a miracle, educate them from the perspective of a health care professional, and assure the patient that the provider will be there for them no matter what.

“We do not expect providers to become theologians or ‘miracle experts,’” said AMEN co-creator Rhonda S. Cooper, MDiv, BCC, the Cancer Center’s chaplain, “but instead to maintain the connection and respond to the patient’s invitation to journey with them through their experience.”

Foundation Announces $250,500 in Scholarships, Fellowship Awards

Sixteen physical therapists (PTs) will receive a combined total of $250,500 in scholarships and 1 fellowship from the Foundation for Physical Therapy (Foundation) through the Promotion of Doctoral Studies (PODS) I and II programs and the New Investigator Fellowship Training Initiative (NIFTI).

The PODS scholarships are part of the Foundation's postprofessional Doctoral Opportunities for Clinicians and Scholarships (DOCS) program. The scholarships are primarily funded by the American Physical Therapy Association’s (APTA) Scholarship Fund, and are designed to assist PTs at various stages in their pursuit of a doctoral degree. The NIFTI is a post-doctoral fellowship intended to fund a mentored research experience in continuation of the development of recent post-professional, doctorally prepared physical therapist researchers.

"The level of excellence of our scholarship and fellowship applications continues to grow," said Foundation Board of Trustees President William G. Boissonnault, PT, DPT, DHSc, FAPTA, FAAOMPT. "The Foundation is proud to support such outstanding physical therapists as they begin their research careers."

MedPAC June Report Subject of Congressional Subcomittee Hearing

Though it contains no formal recommendations, the Medicare Payment Advisory Commission's (MedPAC) June report describes the commission's exploration into the possibility of future changes in several areas, including the idea of paying the same rates to inpatient rehabilitation facilities (IRFs) as are paid to skilled nursing facilities (SNFs) for some types of postacute care. The report was the subject of a June 18 hearing of the House Ways and Means Committee's Health Subcommittee.

The MedPAC report (.pdf), released June 13, is focused on 7 areas: bringing payments in line across fee-for-service, Medicare Advantage, and accountable care organizations (ACOs); measuring quality of care in Medicare; improving risk adjustments; financial assistance for low-income beneficiaries; per-beneficiary payment for primary care; measuring the effects of medication adherence for the Medicare population; and payment differences across postacute settings.

In the postacute settings portion of the report, MedPAC looks specifically at outcomes for major joint replacement, other hip and knee procedures, and stroke, assessing differences between IRFs and SNFs. Although the report notes more analysis must be done to account for variability in stroke treatment, MedPAC's initial findings are that joint replacement and other hip and knee procedures may have similar outcomes, and are "a good starting point for a site-neutral policy," which would aim to bring payments to IRFs more in line with SNF payments.

APTA staff attended the subcommittee hearing, in which Chairman Kevin Brady (R-TX), described MedPAC as a "key nonpartisan advisor with a lot of analytical firepower." MedPAC Executive Director Mark Miller was on hand to testify, and his testimony was posted (.pdf) on the Ways and Means Committee's website.

Burwell Pressed to Expand Payment for Telehealth

The newly confirmed Secretary of Health and Human Services can put another item on her "to do" list—changing Medicare payment policy to allow for accountable care organizations (ACOs) to receive payment for telehealth and remote patient monitoring, including when used as part of physical therapy. At least that's what a coalition of health care-related organizations and a tech corporation would like to see, anyway.

According to a June 11 article in Medscape (free one-time registration required), organizations including the Alliance for Connected Care, the American Telemedicine Association, and the National Association of ACOs have requested that Secretary Sylvia Matthews Burwell look at expanding Medicare's coverage of telehealth beyond beneficiaries in rural areas who must travel to "originating sites." This could be done, the letters argue, if Burwell were to waive restrictions in the Medicare Shared Savings Program.

The letter from the American Telemedicine Association, the Health Information and Management Systems Society, and 10 other nonprofit organizations and for-profit corporations argues that current Medicare regulations "place arduous restrictions on telehealth services which limit patient access to new technologies, effectively discouraging providers from utilizing advanced … solutions in their practices." The letter lists physical therapy as one of the services that could benefit from a new approach that would lower costs and improve outcomes.

The letter estimates that current Medicare restrictions disqualify 80% of Medicare beneficiaries who don't happen to live in a setting defined as "rural," and that coverage is denied for service that originates from a patient's home or other nonmedical location, such as hospice.

BioMed Journal Focuses on Physical Therapy

A recent issue of BioMed Research International is entirely devoted to role of physical therapy in the treatment of chronic wounds, cancer-related lymphedema, and urinary incontinence, with an accompanying editorial stating that "well-documented, promising, and inexpensive methods for physical therapy are necessary" in order to respond to these "common and costly" problems.

The issue is available for free and covers topics including new promising methods in wound healing, physical therapy of urinary incontinence, electromyography and biofeedback in rehabilitation of pelvic floor muscles, and kinesiology taping in lymphedema.

In the issue's editorial, Luther C. Kloth, PT, MS, CSW, FAPTA, joins other editors in writing that the diseases covered in the issue are among "the major health disorders" affecting frail young and older people, and that establishing effective treatment methods is "a pressing issue."

US Health Care Most Expensive, Least Effective Among Wealthy Nations

The news is, there's no news: once again, the United States ranks first among industrialized nations in health care spending but lands near the bottom on most health care outcomes, and winds up in last place overall.

The Commonwealth Fund has released its Mirror Mirror report on health care among 11 wealthy countries, and just as in 2010, 2007, 2006, and 2004, the US is found to have an expensive system that comes in dead last in efficiency, equity, and mortality/life expectancy—and near the bottom in most other measures.

The report compared spending and outcomes among Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the US. The report estimates per-capita health expenditures in the US at just over $8500, almost $3,000 more than the next highest rate (Switzerland), and more than $5,000 above the UK, the country with the highest-rated health care system overall.

Switzerland was ranked second to UK, with Sweden, Australia, and Germany next in line. Canada was ranked second-to-last. Although the US did do well in preventive care, waiting times, and specialist care, it lagged behind in access to services and the ability to receive prompt service from primary care physicians, according to the report.

The so-called "Rock Doc" who pleaded guilty to defrauding Medicare of $2.6 million through bogus physical therapy services has been sentenced to 6 years in prison.

In addition to the billing fraud, Christopher Gregory Wayne, 54, of Miami Beach, Florida, also admitted to illegally prescribing controlled substances and has been ordered to repay Medicare about $1.65 million. The sentencing, which occurred on June 13, was reported in the Wall Street Journal and Miami Herald, among other outlets.

Wayne was the subject of a 2010 WSJ front-page article that tracked nearly $1.2 million in payments from Medicare, mostly for "physical therapy" that was not provided by licensed physical therapists—or not provided at all. The family physician earned his nickname thanks in part to his high-profile lifestyle and punk appearance, complete with spiked blond hair.

According to the Herald article, Wayne told the judge at his sentencing hearing that the billing abuse "was not intentional or malicious." Instead, Wayne claimed that he was simply unaware of 2008 Medicare changes that required his employees to be licensed PTs.

The headline-making nature of Wayne's crimes underscores the importance of maintaining a strong professional understanding of fraud, abuse, and waste. APTA's Integrity in Practice campaign supports physical therapy's high practice standards by helping PTs understand regulations and payment systems, and putting them in touch with tools and resources that promote evidence-based practice, ethics, and professionalism.

6K Steps a Day Linked to Better Function in Individuals With Knee OA

Walking 6,000 steps a day can significantly reduce the risk of functional limitation among people with or at risk of knee osteoarthritis (OA), according to a new study. And it doesn't have to be by way of a structured exercise program—the steps taken in everyday activities can add up to better function in the long run.

In the study, 1,788 participants with or at risk for knee OA were monitored with an ankle pedometer for 2 years. They were not instructed to engage in any formal activity program. Researchers noted at the follow-up that 70% of participants who averaged 6,000 or more steps per day reported no decrease in function, while 70% of those who walked less than 6,000 steps experienced limitations. The findings were published in Arthritis Care & Research (abstract only available for free).

Though authors cited the 6,000-step mark as the point with the “best discriminating ability" relative to functional limitations, they noted that as few as 3,000 steps a day reduced problems, with every additional 1,000 steps lowering limitation risk by at least 16%. The effects were similar between individuals determined to have knee OA at baseline and those found to be at risk for knee OA.

Although the study calls for more extensive studies to reinforce the findings, authors believe that the results point to a possible set of clinical recommendations. "Specifically, walking > 3,000 steps per day may be an initial minimum daily walking goal to recommend," the authors write. "Increasing this amount to walking > 6,000 steps per day may be an ideal amount on an ongoing basis as this threshold best discriminated those who developed functional limitation from those who did not."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

Nearly 10% of Americans Have Diabetes; 25% of Them Don't Know It

Diabetes rates continue to rise at an "alarming" rate, according to the US Centers for Disease Control and Prevention (CDC), which reports that in 2012, the disease was the seventh leading cause of death in the US with a cost of $245 billion in medical expenses and lost work.

According to the CDC's National Diabetes Statistics Report (.pdf), about 9.3% of the US population—just over 29 million people—have diabetes, and 27% of those have not been diagnosed. Another 86 million adults have prediabetes, according to the report, which is based on data from 2012.

Also from the report:

Diabetes rates for Hispanics (12.8%), non-Hispanic blacks (13.2%) and Native Americans/Alaska Natives (15.9%) were markedly higher than the 7.6% rate of non-Hispanic whites. The diabetes rate among Asians was 9%.

Among the estimated 86 million Americans with prediabetes, rates are fairly evenly distributed among non-Hispanic whites (35%), non-Hispanic blacks (39%), and Hispanics (38%).

Diabetes was listed as the primary cause of kidney failure in 44% of all new cases in 2011.

About 60% of non-traumatic lower limb amputations among adults are performed on individuals with diabetes, totaling 73,000 diabetes-related amputations in 2010.

In a press release, Ann Albright, PhD, RD, director of CDC's Division of Diabetes Translation, said that "These new numbers are alarming and underscore the need for an increased focus on reducing the burden of diabetes in this country."

Do you have patients or clients with a recent type 2 diabetes diagnosis? The American Diabetes Association is offering a free guide called "Where Do I Begin," that helps patients and clients understand the fundamentals of the disease and the steps that can be taken to live with it. The booklets are being offered at no charge and can be ordered online.

Health Data Breaches Affect 31.7 Million

It's not exactly the kind of milestone they make greeting cards for: last week, the US Department of Health and Human Services' (HHS) "wall of shame" listings of large-scale health IT data breaches passed the 1,000 mark. The breaches affected 31.7 million people in the US, a number equivalent to 1 in every 10 Americans.

According to a recent article in Modern Healthcare (free registration required), a total of 1,026 breaches that affected 500 or more individuals each are now posted on the HHS site, which houses reports dating back to 2009. That number doesn't include the 116,000 breaches involving the records of fewer than 500 individuals, according to the article.

The HHS Office of Civil Rights, which investigates the breaches, is primarily interested in ensuring compliance; however, monetary settlements have been increasing, with a record $4.8 million negotiated agreement announced in May. According to the Modern Healthcare article, the majority of cases are closed without a settlement.

HIPAA rules can be complex, but the consequences of not understanding them can be serious. APTA provides resources on compliance on its HIPAA webpage.

Taking It to the Streets: Enhancing Local Physical Activity Efforts

The webinar, titled "How Cities, Towns and Counties Can Take Action to Increase Physical Activity," will outline NPAP's recommendations for parks and recreation, public health, and local government. The hour-long presentation will held on June 19 at 3:00 pm ET, and will be led by Russell R. Pate, PhD, professor in the Department of Exercise Science at the University of South Carolina's Arnold School of Public Health, and Jim Whitehead, executive vice president and CEO of the American College of Sports Medicine. Registration is free.

NPAP is a comprehensive strategic plan to promote physical activity in the US. The plan is overseen by the NPAP Alliance, a nonprofit coalition of national organizations. APTA is a member of the Alliance board of directors.

Webinars on PT Clinical Education Vision Ready for Your Input

The first in a series of webinars aimed at getting broad input on a shared vision for physical therapist clinical education are coming soon, and the organizations responsible for the initiative are hoping for broad participation from all stakeholders in physical therapy.

The webinars will take place on Thursday, June 19, 1:00 pm–2:30 pm, ET, and Tuesday, June 24, 7:00pm–8:30 pm, ET. Participants can join as many webinars as they like. There is no registration or reservation process needed to participate in this webinar, and anyone can join.

The first webinar, "Introduction to the Conversation," will focus on the papers and topics from Jette, Recker- Hughes, and Deusinger. Facilitators will be Jody Cormack, PT, DPT, NCS, Valerie Teglia, PT, DPT, NCS, and Stephanie Piper Kelly, PT, PhD.

The webinars are part of a joint effort from The American Council of Academic Physical Therapy (ACAPT), APTA, the Education Section of APTA, and the Federation of State Boards of Physical Therapy (FSBT). The sessions will inform the creation of a shared vision at the Clinical Education Summit planned for October 12–13, 2014, in Kansas City, Missouri. Organizers will use the positions from the JOPTE papers as they have been shaped through discussions to reach agreement on best practices.

Access Instructions

While audio-only access is possible, it is strongly recommended that you be online at a computer screen for full participation. A recording of the webinars will be made available and posted for viewing shortly after each webinar. If you don't have Internet access at the time of the webinar you may find it helpful to review the video portion later.

When the meeting login screen appears, select "Enter as a Guest”; type in your first and last name, your title and/or role in clinical education (eg, DCE, DCCE, CI, practice administrator, student); and click "Enter Room” (for example: Jane Doe, DCCE). The meeting will then launch in your browser, and the meeting room interface will appear.

You will then be prompted to connect to the audio portion of the webinar. To connect using your computer speakers and microphone select the radio button for "using microphone (computer/device).”

To connect by phone, it is preferable that you click the option to let the system call you. The webinar room can call your phone directly, and no participant code is needed. You can access this feature by selecting the radio button "Dial-Out (Receive a call from the meeting)."

If your office phone is connected to your company sound system through an extension (example x321), you will be unable to use the callback feature on that phone. It's recommended that you call in on either a cell or house phone. If that's not accessible, you will need to use your computer speakers and microphone to call in.

PT Helps Make the World 'A Different Place' With Role in Brain-Controlled Exoskeleton

Call it a "brain-mediated technology breakthrough." Call it a "significant paradigm shift." Call it "an elongation of the continuum of movement." The bottom line is this: on Thursday, June 12, 2014, a young man who has paraplegia stood up, walked, and kicked a ball—all by way of an exoskeleton solely controlled by his brain. No joystick, no outside controller, just his own mind.

Actually, maybe the best words for it are "a really, really big deal."

For Michel Landry, PT, PhD, who has been involved in the project for about 2 years, the importance of those first steps simply can't be overstated. As he counted down the hours before the debut of the exoskeleton at the opening ceremonies of the World Cup, he put it very simply. "The world will be a different place after 2 o'clock our time," he said.

And to Landry's great joy (and maybe relief), the world did in fact witness something historic, when 29-year-old Juliano Pinto completed the ceremonial kick off at the Corinthian Arena in Sao Paolo. Pinto has complete paralysis of his lower trunk. Though the moment was lightly covered by the media—and outright overlooked by several outlets—CBS News did publish a photo and story.

Landry spoke with PT in Motion News while he was in Charlotte, North Carolina, to attend APTA's NEXT Conference and Exposition. The conversations took place before the World Cup debut.

Landry was, as they say, pumped.

"No one in the world is doing what we're about to do," he said. "This elongates the continuum of what is now possible, and makes it possible to address the social injustice being faced by people with severe mobility problems."

What Landry's referring to is a $2 million exoskeleton developed through the Walk Again Project (also check out this brief video), a nonprofit international collaboration among the Duke University Center for Neuroengineering, the Technical University of Munich, the Swiss Federal Institute of Technology in Lausanne, the Edmond and Lily Safra International Institute of Neuroscience of Natal in Brazil, The University of California, Davis, The University of Kentucky, and Regis Kopper of The Duke immersive Virtual Environment. The project is led by Brazilian scientist Miguel Nicolelis, MD, PhD.

Landry, program director of the Doctor of Physical Therapy Program at Duke, was asked by Nicolelis to join the effort. Though he describes his part in the project as "very much a supporting role," Landry was involved during the past 2 years, from its initial development in Brazil to the completion of the prototype late last year.

The exoskeleton has been described as an "Iron Man" suit by the media, and in many ways, the prototype is reminiscent of the pumped up ultra high-tech, ultra-cool getup worn by Robert Downy Jr., in the movies. But this exoskeleton isn't a prop—it's the real deal, powered only by brain energy captured via a noninvasive cap. The mechanics respond to brain patterns, and send feedback to additional sensors in gloves worn by the user—in this way, the user gets a "feeling" of more subtle elements of walking such has foot roll and terrain changes. "It's a smart system," Landry said. "As you walk, the user will have motor learning, and will be getting better with every step."

The exoskeleton is the result of work that began with an animal model and a pong-like video game, Landry explained. In the early stages of work, Nicolelis mapped electron "storms" in the brain of a monkey, and soon found that by translating those impulses via sensors on the monkey's head, he could train the animal to play a primitive ball-and-paddle video game simply by thinking about where to move the paddle. The project advanced, and soon Nicolelis found that through the same process, he could train a monkey to make a remote avatar walk—even when the monkey was unable to walk. Essentially, the monkey imagined walking, and brain impulses sparked movement in a set of mechanical legs.

Landry admits that the one-of-a-kind apparatus needs much refinement—"The reality check is, this is a much longer process," he said—but he also understands the nature of the advancement at hand, particularly in light of what it could mean for PTs.

"If we are in fact about optimizing human movement," he said, "we should recognize the social justice issues that are at stake here, and we need to be doing whatever we can to adopt new environments so that people with these injuries can experience movement and be viewed as equals in our world. High technology is all around us. Why can't we bring that high technology into the world of disability?"

Landry is eager to see the technology be refined, mass produced, and made less expensive. The choice of the first user of the exoskeleton was a conscious one—they wanted to showcase the device being used by a youth from one of the world's poorest areas.

Though he had yet to see the kick at the World Cup and was more than a little nervous about how the technology would react to multiple unpredictable factors—the weather, the heat, grass conditions, you name it—he was certain that history was about to be made.

"This is like the space race," he said. "Everyone has been trying to get to the moon, and we got there first."

PT-PTA Teamwork Highlighted in Video Series

A collection of short videos from APTA makes it clear that tales of a dynamic duo's success aren't just found in comic books and Fred Astaire movies—they're the stuff of real-world practice relationships among physical therapists (PTs) and physical therapist assistants (PTAs).

The association's Supervision and Teamwork webpage now includes "Success Stories From the Field," a set of short videos that explore how PTs and PTAs combine talent and expertise to extend the reach of physical therapy, ensure consistency of care, increase efficiencies, and keep costs down. The profiles help to show how the PT-PTA team can not only benefit patients and clients, but enrich providers' own experiences by establishing an atmosphere of respect and collaboration.

The videos now available are part of a planned series, additional installments of which are being recorded during the APTA NEXT Conference and Exposition being held June 11-14 in Charlotte, North Carolina.

Want to learn more about the PT – PTA team experience? Contact PTA@apta.org.

Large-Scale Trial Links Activity to Lowered Risk of Mobility Loss

In what its authors call "the largest and longest duration randomized trial of physical activity in older persons," a new study asserts that a carefully structured, moderate physical activity program can reduce risk of losing the ability to walk without assistance.

The Lifestyle Interventions and Independence for Elders (LIFE) trial included 1,635 sedentary men and women aged 70-89 at risk of disability. Participants were randomly assigned to a program of structured, moderate-intensity physical activity or to a health education program focused on topics related to successful aging, and then monitored for 2.6 years. The diverse participants were recruited from urban, suburban, and rural communities across the US. Results are available for free in the May 27 issue of JAMA, the Journal of the American Medical Association.

The physical activity intervention involved walking as well as strength, flexibility, and balance training. Participants in this group attended 2 center-based visits a week in individualized sessions that worked toward a goal of 30 minutes of walking daily at moderate intensity, 10 minutes of primarily lower extremity strength training by means of ankle weights (2 sets of 10 repetitions), 10 minutes of balance training, and large muscle group flexibility exercises.

Participants in the health education program attended weekly education sessions on healthy aging for the first 26 weeks of the intervention, and then monthly sessions. According to the study's authors, the workshops "included topics relevant to older adults," but did not address physical activity. Participants did receive "a 5 to 10-minute instructor-led program of gentle upper extremity stretching or flexibility exercises."

Participants were assessed every 6 months at clinic visits over 2.6 years. Clinicians performing the assessments were not aware of which participants were in which groups.

Results showed that the incidence of major mobility disability (defined in this study as the inability to complete a 400-m walk test within 15 minutes without sitting and without the help of another person or walker) was markedly higher among the education group, with 35.5% of that group experiencing the disability compared with 30.1% of the physical activity group. Additionally, persistent mobility disability was experienced by 19.8% of the education group and 14.7% of the physical activity group. Authors also write that participants who began the study with lower baseline levels of activity received "considerable benefit" from the activity intervention.

"These results suggest the potential for structured physical activity as a feasible and effective intervention to reduce the burden of disability among vulnerable older persons, in spite of functional decline in late life," authors write. The researchers were supported by the National Institute on Aging (NIA) and the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health.

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

Registry to Move Ahead Through APTA Collaboration With Quintiles

The largest, most comprehensive electronic repository for physical therapy outcomes is ready to move from planning to reality with the announcement of a collaboration between APTA and Durham, North Carolina-based Quintiles.

According to a joint news release, APTA and Quintiles will be working together to develop the Physical Therapy Outcomes Registry, an initiative that will be "unlike any other existing physical therapy registry.” Among other features, the registry will provide data “across the continuum of care" and "will align with current and future quality and compliance programs required by payers, such as the Physician Quality Reporting System."

APTA and Quintiles describe the registry as a "hub and spoke" system in which outcomes information from a wide range of sources will be aggregated across patient populations and clinical settings. APTA President Paul A. Rockar Jr, PT, DPT, MS, said that the registry aims to become "the most comprehensive database for demonstrating the value of physical therapy in the near future and will further the development of standards of practice and quality reporting requirements."

Recruitment of users for a pilot version of the registry will begin in the third quarter of 2014, with a full launch planned for early 2015.

“Working together with APTA and leveraging our expertise in designing and implementing registries, our goal is to build a new registry that will provide clinicians and practices with benchmark data to improve healthcare delivery and achieve better patient outcomes,” said Cynthia Verst, president of Real-World & Late Phase Research at Quintiles.

The association selected Quintiles for this initiative based on Quintiles’ experience in post-marketing research, multistakeholder strategy, and systems-oriented registry design and development. Quintiles is world’s largest provider of biopharmaceutical development and commercial outsourcing services, with a network of more than 29,000 employees conducting business in approximately 100 countries.

“APTA is in a unique position to help physical therapists comply with requirements by payers, employers, certification boards, healthcare facilities, and other entities to ensure participation, accreditation, and adherence,” said Rockar. “We are committed to providing data to advance physical therapist practice, education, and research, and look forward to working with Quintiles in this endeavor.”

Physical Therapy Outcomes Registry Dispatch from NEXT 2014 in Charlotte

HHS Lays Out Vision for Health Care IT

By 2024, health care consumers will access, manage, and share their own health care data with multiple providers through a "seamless" set of technologies; primary care providers will access patient genetic information and research on medication efficacy to pinpoint the best treatments for individual patients; and all participants in the health care system—including patients—will contribute to a massive body of data that can be used to further research.

The "interoperable health IT infrastructure" report outlines goals for the next 3, 6, and 10 years that put emphasis on hammering out the technical aspects of interoperability in the earlier stages of development, and growing the use of an integrated system by way of policy and business practice changes later on. At every point along the way, the report states, work will be guided by 10 principles, among them a respect for the differing needs of health care providers and institutions, an acknowledgement that change will occur at different rates for different groups, and an understanding that privacy and security must be a central consideration in any new approach.

ONC admits that the road ahead could be a long one given the current state of health IT. "It is not the norm that electronic health information is shared beyond groups of health care providers who subscribe to specific services or organizations," write the report's authors. "Electronic health information is also not sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed with vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care. We must learn from the important lessons and local successes."

Still, these are issues that can be overcome, according to the vision plan. "HHS is fully committed to ensuring ubiquitous, standards-based interoperability of health information across all care settings through a multi-year approach," authors write. "No one person, organization, or government agency alone can realize this vision of an interconnected health system. But together, we can achieve the promise and potential of health information technology to improve the health of all."

ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004 and was legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.

Challenge Gets Families Moving Together

For families looking for ways to stay active together, summer just got more challenging—in a fun way, that is. With prizes.

APTA and its Section on Pediatrics are encouraging the whole family to get involved in physical activity with its "Summer Fit Family Challenge," a program that promotes shared physical activities that make the most of summer. Members are encouraged to share information on the program with patients, clients, and members of the community—as well as with their own families.

The challenge? Families download a list of 15 fun physical activities, then try to do as many as possible over the summer. Activities range from fruit-picking at a local orchard, to finding a new lake or beach and taking a dip, to simply taking the time to explore a city on foot or bike. Families who take photos of themselves participating in the challenge can share their photos on Facebook, Instagram, and Twitter using the hashtag #FitFam14, and will be entered to win prizes.

The contest will run from June 9 to September 1, 2014.

"There is a summer activity to suit everyone," said Joseph Schreiber, PT, PhD, PCS, president of APTA's Section on Pediatrics in a news release. "Becoming fit as a family provides children a foundation for lifelong healthy habits."

The Summer Fit Family Challenge is featured in Move Forward PT.com, the consumer-focused website that helps the public better understand the value of physical therapists and physical therapist assistants.

"Part of being a pediatric physical therapist is working not only with a child, but with the whole family," said Schreiber. "Physical therapists are a family's ally in motion."

Jump in Knee Replacement Surgeries Linked to Rise in Obesity Rate

The rate of total knee arthroplasty (TKA) in adults has surpassed the rate of total hip arthroplasties (THA) over the past 20 years, and researchers believe overweight and obesity is the reason.

A study published in the June 4 Journal of Bone and Joint Surgery (abstract only available for free) reviewed the rise in hip and knee replacement surgeries and found that while both procedures are occurring at higher rates than 20 years ago, total knee replacements have "far outpaced" hip replacements. In 1993, surgeons performed about 1.16 knee replacements for every hip replacement surgery. By 2009, that rate had increased to 1.60 knee replacements per hip procedure. Over the time period they studied, the THA rate doubled, while the TKA rate more than tripled.

Authors found that when they compared these data with BMI information from individual patients, "individuals with a body mass index of ≥25 kg/m2 were responsible for 95% of the differential increase in [TKA] over [THA] volumes."

The rate of growth in TKA rates echoed the increase in overweight and obesity among age groups. The number of patients ages 18 to 64 undergoing TKA rose 56% in 20 years—an increase that authors feel is reflective of that same age group's more marked rise in obesity and overweight compared with individuals 65 and older.

At the same time the numbers of procedures were on the rise, physician compensation was falling more or less equally for both replacement surgeries, with per-case reimbursements falling to $1,560 for TKA, and to $1,460 for THA. Authors believe that the similarity in rates makes it unlikely that surgeons are performing TKA more frequently than THA for reimbursement reasons. Researchers also discounted changes in length of stay, and in-hospital mortality as possible reasons for the growth.

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

Burwell Confirmed for HHS

Sylvia Matthews Burwell, former director of the US Office of Management and Budget (OMB), has been confirmed by the Senate to take over as Secretary of the Department of Health and Human Services (HHS). Burwell replaces Kathleen Sebelius, who stepped down in April.

Burwell was confirmed in a bipartisan vote of 78 to 17. In a Washington Post report on the confirmation, Sen Ron Wyden (D-Ore), whose committee nominated Burwell to the full Senate, is quoted as saying that Senate support was strong because "she really is that good, she really is that capable, and she really is that qualified."

Before her role at OMB, Burwell, 48, worked for the Bill and Melinda Gates Foundation, the Wal-Mart Foundation, and in the administration of President Bill Clinton.

PTs in the ED: New Resources Available

A new set of resources on the APTA website can help physical therapists (PTs) make the case for the PT's role in an emergency department (ED) and gain a better understanding of the skills required to make that role effective.

The association released a letter to the editor responding to a May 29 healthbeat newsletter article titled "4 ways to put off joint replacement." The article listed weight loss, proper joint use, injections of steroids or other compounds, and pain reduction through NSAIDS, but made no mention of the ways in which a PT can help.

"Your readers would have benefited by knowing that physical therapist services can provide a conservative, cost-effective, and evidence-based alternative for those affected by joint pain," writes letter author Emilio Rouco, APTA's director of public and media relations.

Rouco continues by highlighting the ways PTs can increase strength, endurance, and function; how PTs can help patients manage pain; and the approaches PTs can use to prepare a patient for joint replacement surgery if nonsurgical approaches aren't working, as well as help the patient recover afterwards. "Physical therapists, who are experts in restoring and improving motion in people's lives, can help patients avoid surgery and its risk of complications in many instances," he writes on behalf of APTA.

NIH Backs $4.5 Billion Brain Research Project

A "moon shot initiative" to uncover the mysteries of brain function received significant support from the US National Institutes of Health (NIH), which is recommending that the project be funded to the tune of $4.5 billion over the next 12 years.

A federal report recently released by NIH states that the money will be necessary to fully implement the Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. The new federal funding would be released over 10 years beginning in fiscal year 2016. NIH already announced an investment of $40 million in fiscal year 2014, and President Obama has made a request for $100 million for NIH's component of the initiative in his fiscal year 2015 budget.

According to a news release from NIH, the initiative will focus on 7 major efforts: determining the roles of different brain cell types in health and disease, generating brain "circuit diagrams," producing a dynamic picture of brain function, linking brain activity and neural circuit dynamics to behavior, creating a framework for understanding mental processes, developing technologies to understand brain disorders, and integrating findings to discover "dynamic patterns of neural activity."

"As the Human Genome Project did with precision medicine, the BRAIN Initiative promises to transform the way we prevent and treat devastating brain diseases and disorders while also spurring economic development," said NIH Director Francis S. Collins, MD, PhD. "While these estimates are provisional and subject to congressional appropriations, they represent a realistic estimate of what will be required for this moon shot initiative."

Members are encouraged to participate in a series of webinars beginning June 19. The webinars will focus on key issues presented in the JOPTE position papers and will provide more opportunities for input. Details on webinar dates and times can be found online. The webinars will be open to anyone who wants to participate, and will not require registrations or reservations. Information on how to access to the webinars will be shared soon.

The offerings over the summer will inform the creation of a shared vision at the Clinical Education Summit planned for October 12–13 in Kansas City, Missouri. Organizers will use the positions from the JOPTE papers as they have been shaped through discussions to reach agreement on best practices. Participants at the summit will include 2 representatives from each ACAPT institution, members of APTA leadership, and stakeholders both within and outside of the physical therapy profession. The meeting immediately follows the 2014 Educational Leadership Conference.

What You Don't Know Can Hurt You: Get the Latest From APTA on Fraud, Abuse, and Waste

Avoiding risk is easier when you understand what the dangers are, and where they exist. A new resource from APTA helps physical therapists (PTs) do just that by taking a careful look at fraud, abuse, and waste.

Preventing Fraud, Abuse, and Waste: A Primer for Physical Therapists (.pdf) is a free guide that examines not only the laws around these issues but the ways in which a physical therapist's (PT) relationships with payers, referral sources, and patients can set the stage for potential problems. The 20-page booklet is written in an easy-to-read style and includes many real world examples of the ways in which PTs can intentionally or unintentionally cross the line, as well as information on how to comply with the relevant laws and regulations and avoid risk.

The primer is part of APTA's Integrity in Practice campaign, an initiative that supports physical therapy's high practice standards. The campaign helps PTs understand regulations and payment systems, and puts them in touch with tools and resources that promote evidence-based practice; ethics; professionalism; prevention of fraud, abuse, and waste; and more.

$70 Million Falls Prevention Study Launched

A $30 million, 5-year project will use large-scale clinical trials to create a "cohesive intervention" for falls reduction. The project, announced by the National Institutes of Health (NIH) and the Patient-Centered Outcomes Research Institute (PCORI), will study over 6,000 adults 75 and older in 10 trial sites across the country.

The study is being led by researchers from the Yale, Harvard, and University of California – Los Angeles medical schools, and will include more than 100 researchers. First-year funding of $7.6 million was awarded on June 1 from the NIH/PCORI Falls Injuries Prevention Partnership.

"Previous studies have analyzed risk factors for falls and fall injuries, along with interventions to prevent them," according to a news release from NIH. "But the best evidence about how to reduce falls has not been broadly applied."

The first year of the study is a pilot phase in which researchers will assess elements of the proposed intervention with smaller numbers of participants. After the first year (and pending approval by NIH and PCORI), the full trial will begin and last for 18 months. Participants will be followed for up to 3 years.

"The trial will focus on clinical practice redesign, while also using interventions tailored to individuals," said Shalander Bhasin, MD, 1 of the 3 leaders of the study. "The goal is to recognize and overcome challenges in implementing falls injury prevention strategies in diverse health systems." The selected clinical sites are included in the news release.

WCPT has also opened its call for abstracts for the congress, with an October 31 submission deadline. In addition, the confederation offers a mentoring program for anyone with little or no experience in submitting an abstract for a scientific congress.

The WCPT Congress is the world's largest international physical therapy gathering. APTA is a member of WCPT.

Apple Announces System to Coordinate Health Apps

Apple has announced that a new suite of in-device software coming to its next operating system (iOS8) will allow users' health data to be coordinated between separate health-related apps, making it possible to create a customizable health data dashboard that could be shared with health care providers. Called "HealthKit," the new system was unveiled on June 2 at Apple's Worldwide Developers' Conference.

Currently, health-related apps such as Fitbit, Nike Run, and iBP Blood Pressure capture specific data that can only be accessed through that particular app, creating information silos that can make it difficult for consumers to get a more wholistic picture of their health. According to an article in Macworld, the HealthKit system, through its outward-facing Health app, "is designed to give users a big-picture look at their entire health profile: exercise, sleep, eating, and even metrics like blood pressure and glucose levels."

Nike, Fitbit, and iHealth will be among the first apps to be integrated into Health. Apple also announced a partnership with the Mayo Clinic to develop an app that evaluates individual patient metrics that in turn can be shared with a health care provider—or prompt the health care provider to contact the patient directly.

Exercise By Any Other Name Just a Bit Sweeter, According to Study

What's in a name? Calories, apparently.

According to a recently published open access article in Marketing Letters, men and women who think a physical activity program is meant to be "fun" and not "exercise" tend to make healthier after-activity food choices.

Authors describe an experiment in which 56 healthy adult women were given maps of an outdoor 1-mile walking route and told that they would be served lunch after the walk. The women were then divided into 2 groups: one group was told that the walk was exercise and that they should be aware of their performance around the course; the other group was provided with headphones and music and asked to think about the sound quality of the music while enjoying themselves as they walked.

At the post-walk lunch, the women who were told they were exercising reported feeling more tired and irritable than the women who were walking for pleasure, and they tended to consume more sugary foods.

The general results were the same in a follow-up experiment in which 2 groups consisting of both women and men were instructed to walk a 1-mile route, with one group told they would be exercising, and the other told they would be sightseeing. When invited to help themselves to candy after the walk, the "exercise" group generally took more candy than the "sightseeing" group.

In a subsequent experiment, runners completing a marathon relay race were asked whether they had enjoyed their experience, and then were offered the choice of a chocolate bar or cereal bar as a snack. Researchers found that runners who said they didn't enjoy themselves tended to opt for the chocolate bar.

"Across 3 studies, in both lab and field settings, we found that framing a physical activity as fun (vs exercise) influenced participants' subsequent behavior," authors write, noting that the effects were consistent after controlling for BMI. The study was the focus of a recent blog post in the New York Times.

Research-related stories featured in News Now are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

The Government Accountability Office (GAO) report on self-referral in physical therapy released June 2 shows that there "does appear to be a relationship between self-referring providers and the overall number of individuals referred for physical therapy," according to a joint Congressional statement issued soon after the report was made public.

In the joint statement on the physical therapy report, members of the Senate Judiciary, House Ways and Means, and House Energy and Commerce Committee leadership characterized the most recent GAO report as "showing self-referring providers refer more individual patients for physical therapy in Medicare than non-self-referring providers."

The report, the fourth and final in a GAO series on medical self-referral, was less conclusive in its findings than previous investigations—a shortcoming that APTA largely attributes to methodological limitations, according to a recent association statement.

Members of the House and Senate committees acknowledged the differences from previous reports, but described the findings as part of a larger body of evidence showing that "financial incentives, not patients' needs, are driving some referral patterns," according to House Ways and Means Committee Ranking Member Sander Levin (D-Mich).

Senate Judiciary Ranking Member Chuck Grassley (R-Iowa) described the report's findings as "less clear" than previous reports, but he said that "we need to continue to monitor this area to be sure doctors aren’t unnecessarily referring patients for physical therapy when they have a financial interest."

“Along with my colleagues, I remain concerned about the effect of physician self-referral driving unnecessary use of health care services,” said Henry Waxman (D-Calif), ranking member of the House Energy and Commerce Committee. “The findings in today’s report, while not as direct as other reports on this topic, raise additional questions for exploration.”

The APTA statement calls for a more informed analysis, and urges policy makers to require all self-referring providers to notify patients of their right to see the provider they choose, and share lists of a variety of local physical therapists with patients. The association also recommends that Medicare claim forms require a unique modifier that identifies when any service is being received through self-referral.

APTA also continues to advocate for H.R. 2914, federal legislation that would remove physical therapy from the in-office ancillary services exception to the Stark law.

New Centralized Pain Research Database Launched

A new interagency database is offering 1-stop information on a wide range of government-supported research on pain.

The Interagency Research Portfolio launched last week combines information from the National Institutes of Health (NIH) the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Department of Veterans Affairs (VA), and the Department of Defense (DOD).

Users of the database can search over 1,200 research projects in a multi-tiered system. In Tier 1, grants are organized as basic, translational (research that can be applied to diseases), or clinical research projects. In Tier 2, grants are sorted among 29 scientific topic areas related to pain, such as biobehavioral and psychosocial mechanisms, chronic overlapping conditions, and neurobiological mechanisms.

A long-awaited report from the US General Accountability Office (GAO) on physician self-referral in physical therapy is short on "definitive conclusions" and overlooks many of the realities of physical therapist practice and patient populations, according to a recent statement from APTA.

The association statement reaffirms APTA's commitment to working with GAO to foster a better understanding of self-referral and its impact, but also reasserts its position that physical therapy should not be characterized as an "in-office ancillary service" and should have never been included in the self-referral loophole to begin with.

In a report that APTA says "underscores the need for further research," GAO turned its attention to physical therapy, the last of 4 health care professions that were studied to determine the causes and percentage of increases, if any, in procedures when a physician refers a patient for treatment or services in facilities owned by the physician. Earlier studies that focused on imaging services, anatomic pathology, and radiation therapy for prostate cancer showed that the number of procedures—and costs—do in fact increase in self-referral arrangements. The study on physical therapy yielded less definitive results, due in large part to methodology limitations that GAO readily acknowledged.

Among the shortcomings cited by the association: a lack of data on severity of condition, impairments, and comorbidities, as well as on quality of care provided. "Data on the frequency of visits and total expenditures are irrelevant without knowing patient severity and outcomes," according to the statement.

The few areas in which definitive findings could be reached involved data that show a "sharp increase" in referral rates for physicians who transition to a self-referral practice model, according to the statement.

The statement also questions the report's classification of all institutional care as "non-self-referred" care, which APTA argues is more likely to involve patients with complex conditions. Given that 40% of physical therapy services billed under Medicare come from skilled nursing facilities alone, APTA says, the unbalanced nature of the 2 groups being studied "clearly skews data and clouds results."

"The bottom line is that the GAO report is unable to reach any definitive conclusions ... so the need for further research continues," according to the statement.

At some level, GAO seems to agree. The report acknowledges limitations in the methodology used, and states that "it is outside the scope of this report to examine the medical necessity, clinical appropriateness, or effectiveness of [physical therapy] services beneficiaries received."

In addition to calling for a more informed analysis, APTA is also urging policy makers to require all self-referring providers to notify patients of their right to see the provider they choose, and share lists of a variety of local physical therapists with patients. To help refine data collection, the association is also recommending that Medicare claim forms require a unique modifier that identifies when any service is being received through self-referral. APTA also continues to advocate for H.R. 2914, federal legislation that would remove physical therapy from the in-office ancillary services exception to the Stark law.

Direct Access to PTs Now a Reality in Oklahoma

Oklahomans now have direct access to evaluation and treatment by physical therapists (PTs). On May 23, Oklahoma Gov Mary Fallin signed HB 1020, which allows patients to be evaluated and treated by a PT for 30 days without a referral from a physician or other provider. Previously, state law required a physician referral for any kind of treatment, though PTs were allowed to provide an evaluation without a referral. The new law takes effect November 1, 2014.

"Ensuring patient access is a cornerstone of APTA's vision and mission," said APTA President Paul A. Rockar Jr, PT, DPT, MS, in a news release. "I want to thank Rep Arthur Hulbert, PT, DPT, for authoring this bill, and Rep Sean Roberts, PT, for coauthoring. As physical therapists, Rep Hulbert and Rep Roberts truly understand how important this legislation is and the positive impact it will have on individuals who need the services of physical therapists."

The bill was promoted by the Oklahoma Chapter of APTA (OPTA). OPTA President Debra Christian, PT, DPT, said, "This is an historic time for the Oklahoma Chapter and the culmination of many years of work by numerous individuals. I want to thank the OPTA Board of Directors for their commitment to this effort, as well as our membership who stepped up in a big way over the past couple of months." Christian also acknowledged the leadership of Jeffrey Jankowski, PT, immediate past president of OPTA.

Brandon Trachman, PT, MPT, OCS, OPTA legislative chair, added, "HB 1020 is an enormous victory for Oklahomans, who will now be able to take a more active role in their own health care and choose safe and effective treatment directly from physical therapists. The passage of HB 1020 would have never been possible without the diligent and tireless efforts of Reps Hulbert and Roberts, as well as Sen Kim David, who authored a version of this bill in the Senate."

APTA provided a direct access grant to the Oklahoma Chapter, as well as additional financial support for the chapter's lobby day at the state capitol.

The success in Oklahoma means that 49 states and the District of Columbia now allow some level of treatment by a PT without referral. Direct access legislation is pending in Michigan, the final state with no form of direct access to treatment by PTs. Michigan SB 690 recently received a unanimous vote in the Senate and now awaits action in the state House of Representatives.

Obesity Goes Global

When it comes to rates of obesity, the world isn't so small after all.

A new study published in the May 29 Lancet reports the results of a worldwide study of obesity and overweight, and found that rates have increased between 1980 and 2013 by 27.5% for adults and 47.1% for children. Although rates vary by region, increases can be found almost everywhere in the world, authors write, and when it comes to the battle against obesity, "no national success stories have been reported in the past 33 years."

During the 33-year timeframe reviewed, worldwide obesity rates rose from 28.8% to 36.9% in men, and from 29.8% to 38% in women. Children and adolescents also experienced "substantial" increases in obesity and overweight, with developing countries rising from 8.1% to 12.9% in boys, and from 8.4% to 13.4% in girls. Among developed countries, the child and adolescent rates rose from 16.9% to 23.8% of boys, and from 16.2% to 22.6% of girls. Authors defined overweight as BMI between 25 and 30 kg/m2 and obesity as BMI of 30 kg/m2 for adults, and used the International Obesity Task Force definition for children.

The findings "show that increases in the prevalence of overweight and obesity have been substantial, widespread, and have arisen over a short time," authors write.

The United States continues to lead the world in the sheer number of obese people in the world, accounting for 13% of the estimated 671 million obese individuals worldwide. China and India were, respectively, the next largest countries with the highest populations of obese individuals, but combined they only accounted for 15% of the world's obese people. Current estimates are that about one-third of all adults in the US are obese.

Among other findings in the report:

In developed countries, more men than women were overweight and obese; in developing countries, the opposite is the case.

Obesity rates increased most rapidly between 1992 and 2002, and have slowed somewhat, particularly in developed countries.

Overweight and obesity rates peak at about 55 years for men and 60 years for women in both developed and developing countries, but rates are much higher in developed countries.

Prevalence of obesity was greater than 50% for men in Tonga, and for women in Kuwait, Kiribati, the Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa.

The largest increases in the rates of obesity during the study period were in Egypt, Saudi Arabia, Oman, Honduras, and Bahrain for women, and in New Zealand, Bahrain, Kuwait, Saudi Arabia, and the US for men.

Authors did not offer an explanation for the rates of increase but pointed to other studies that cite increased calorie intake, changes to diet composition, decreased activity, and changes to the gut microbiome.

The report says that without a significant increase in attention to the problem through both research and policy, the upward trend is likely to continue, despite a World Health Organization effort to stop the rise in obesity rates by 2025. "No countries have well documented downward trends in the past 3 decades," the authors write. "Our analysis suggests that this target is very ambitious and unlikely to be attained without concerted action and further research to assess the effect of population-wide interventions, and how to effectively translate that knowledge into a national obesity control program."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.